ERISA-Fifth Circuit Upholds Plan Administrator’s Denial Of Plan Benefits To Cover Bariatric Surgery

The case of Rittinger v. Healthy Alliance Life Insurance Company, No. 17-20646 (5th Cir. 2019), involves a bariatric surgery gone wrong and the ensuing clash over insurance coverage.

In this case, Karen Rittinger was the beneficiary of an ERISA-covered plan. Healthy Alliance Life Insurance Company offered the plan and Anthem Blue Cross Blue Shield (“Anthem”) administered it. In October 2014, Rittinger underwent bariatric surgery. Complications arose requiring follow-up surgery and intensive care. Anthem denied preauthorization (and thus plan benefits) for both the bariatric surgery and the follow-up surgery, writing, “We cannot approve coverage for weight loss surgery (bariatric surgery) or hospital care after this surgery. Bariatric or weight loss surgery is an exclusion in your health plan contract.” The contract, though, had an exception to this exclusion for “excessive nausea/vomiting.” Arguably, the exception applied to Rittinger. Nevertheless, Anthem denied her claim for benefits in both a first and second-level appeal, on the basis of the plan’s exclusion of bariatric surgery. Having exhausted the plan’s internal remedies, Rittinger filed suit in district court. The district court overturned Anthem’s decision, on the grounds that Anthem did not interpret the plan correctly and did not give enough weight to Rittinger’s vomiting problem. Anthem appealed. Rittinger filed a cross-appeal to determine the exact dollar amount of the damages she is owed.

Upon reviewing the case, the Fifth Circuit Court of Appeal (the “Court”) noted that Anthem’s decision is entitled to a highly deferential standard of review.  The Court concluded that, given this level of review, the Court could not say that Anthem, the plan administrator, abused its discretion in either the first or second internal appeal. Therefore, the Court overturned the district court’s decision. Because the Court agrees with Anthem, it also held that Rittinger’s cross-appeal is moot.

 

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